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These conditions develop as an abnormal adaptation to a traumatic event and are characterized by intrusive symptoms such as nightmares and flashbacks, avoidance of reminders of the trauma, negative changes in cognition and mood, and increased sensitivity and reactivity showing up as hypervigilance (perpetual scanning of the environment to search for anything threatening) and irritability.
Some evidence suggests ECS dysfunction contributes to trauma-related disorders. Reduced blood levels of the endocannabinoid anandamide (AEA), abnormal CB1 receptor signaling, and a compensatory increase of CB1 receptor availability are associated with PTSD and correlate with the degree of intrusive symptoms [41]. In one study, among 46 individuals in close proximity to the World Trade Center at the time of the 9/11 attacks, the 24 subjects who met diagnostic criteria for PTSD had significantly lower circulating levels of the endocannabinoid 2-AG than those who did not have PTSD. Those with the lowest levels of AEA levels had the most intrusive symptoms, consistent with animal data indicating that reductions in AEA promote retention of aversive emotional memories [42]. The ECS is an important part of our ability to extinguish the emotional charge behind, and even forget our traumatic memories.
PTSD is often resistant to traditional antidepressant and anti-anxiety medications, in part because these treatments fail to address memory-related dysfunction seen in people with PTSD, such as the inability to extinguish learned fear responses, to suppress retrieval of traumatic memories, to acquire safety signals, and to dampen the over-consolidation [43] process taking place right after reexperiencing symptoms.
Cannabinoids are promising for treating PTSD due to their dual anti-anxiety and memory-modulating effects. Animal and early clinical research have produced encouraging results targeting the extinction of fear memories, which could “reduce the conditioned fear and anxiety responses triggered by trauma reminders, increasing patients’ general ability to actively cope with the trauma without affecting the original memory trace” [44].
I have observed this benefit in some of my patients. For example, a 34-year-old veteran who was injured by a roadside explosive returned to civilian life with recurrent episodes of extreme distress most commonly triggered by visual stimuli while driving, such as a red flag tied to the end of lumber extending from the back of a pickup truck. He explained that every time this happened, he would pull over, take an inhalation or two of THC-rich cannabis from a pipe he kept in his car, and then meditate for 15–30 min before continuing on his way (assuring me he avoided driving until any potential impairment had subsided). One day he was proud to report that seeing a red flag on the way to our office visit, for the first time since his injury, elicited no adverse response. Perhaps his use of cannabis with every trigger enhanced “fear extinction learning” – he was able to learn that the visual stimulus was actually non-threatening.
Several experimental human studies have indicated that cannabinoids can be helpful in fear extinction, potentially improving the benefits of non-pharmacological treatments for trauma like cognitive and behavioral therapies. For example, a single 7.5-mg dose of THC administered 2 hours before fear extinction learning, compared to placebo, resulted in significantly decreased threat responses 1 day and 1 week later, accompanied with functional brain imaging data showing a significant effect on the connectivity of threat-detection networks [45]. Another study found that 32 mg of inhaled CBD enhanced consolidation of fear extinction learning in humans [46]. Both suggest that cannabinoids may have potential as an adjunct to extinction-based therapies for anxiety disorders.
Among 136 individuals receiving cognitive behavioral therapies for co-occurring PTSD and substance use disorders, higher cannabis use was associated with greater PTSD symptom severity early in treatment but lower PTSD symptom severity later in treatment; the authors suggested that cannabis may have interacted synergistically with psychological treatment to reduce PTSD symptoms [47].
[41] Orsolini, L., Chiappini, S., Volpe, U., De Berardis, D., Latini, R., Papanti, G. D., & Corkery, J. M. (2019). Use of medicinal cannabis and synthetic cannabinoids in post-traumatic stress disorder (PTSD): A Systematic Review. Medicina, 55(9), 525.
[42] Hill, M. N., Bierer, L. M., Makotkine, I., Golier, J. A., Galea, S., McEwen, B. S., … & Yehuda, R. (2013). Reductions in circulating endocannabinoid levels in individuals with post-traumatic stress disorder following exposure to the World Trade Center attacks. Psychoneuroendocrinology, 38(12), 2952-2961.
[43] Consolidation is the process of transforming a short-term memory into a long-term memory. People who reexperience trauma can increase the consolidation of the traumatic memory with each reexperiencing episode, worsening the condition.
[44] Berardi, A., Schelling, G., & Campolongo, P. (2016). The endocannabinoid system and post traumatic stress disorder (PTSD): From preclinical findings to innovative therapeutic approaches in clinical settings. Pharmacological Research, 111, 668–678.
[45] Hammoud, M. Z., Peters, C., Hatfield, J. R. B., Gorka, S. M., Phan, K. L., Milad, M. R., & Rabinak, C. A. (2019). Influence of Δ9-tetrahydrocannabinol on long-term neural correlates of threat extinction memory retention in humans. Neuropsychopharmacology, 44, 1769–1777. https://doi.org/10.1038/s41386-019-0416-6
[46] Das, R. K., Kamboj, S. K., Ramadas, M., Yogan, K., Gupta, V., Redman, E., … & Morgan, C. J. (2013). Cannabidiol enhances consolidation of explicit fear extinction in humans. Psychopharmacology, 226(4), 781-792.
[47] Ruglass, L. M., Shevorykin, A., Radoncic, V., Smith, K. M., Smith, P. H., Galatzer-Levy, I. R., … & Hien, D. A. (2017). Impact of cannabis use on treatment outcomes among adults receiving cognitive-behavioral treatment for PTSD and substance use disorders. Journal of Clinical Medicine, 6(2), 14.
